For our June #JHSJC event, we discussed the following two articles:
- Risk of Amyloidosis and Heart Failure Among Patients Undergoing Surgery for Trigger Digit or Carpal Tunnel Syndrome: A Nationwide Cohort Study With Implications for Screening
- The Reliability of the CTS-6 for Examiners with Varying Levels of Clinical Experience
We thank everyone who joined us for the conversation. We’ll be taking a short break for the summer but will return in September! Please check back soon for article summaries and discussion points.
When we return, we’ll continue to use the TwChat platform. Please review the information here on how to use TwChat and join us in the fall!
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome to the June discussion! if you are not using twchat be sure to insert the JHSJC hashtag with your tweets! #jhsjc
Let’s begin with the paper by Sood and Lipira. Amyloidosis and hand surgery – it’s a real thing! #jhsjc
RyanC @RPCalfeeSTL:
Looking forward to learning from others about amyloidosis #jhsjc
Brent Graham @BgTalkinman:
I’ve been in practice a long, long time and the idea that I was treating patients who might have amyloidosis never occurred to me. #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
that’s a great point, but to be fair, it’s only been in recent years that novel therapies for ATTR amyloidosis have come out such that early diagnosis can really benefit our patients #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
Agreed – I’m trying to not feel guilty! #jhsjc
Brent Graham @BgTalkinman:
Let’s discuss a few methodologic points Is the sample used for the study, VHA patients, likely to be generalizable across the entire population? Is there risk that the data is flawed in some way, dependent as it is on administrative data? #jhsjc
David Ring @DrDavidRing:
I’m worried about excessive testing and overdiagnosis. There are a lot of steps, of experimental evidence, needed before we change our practice of considering median neuropathy at the carpal tunnel and trigger digit idiopathic #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Seemingly the numbers suggest that there is a clear association between either #CTR or #triggerrelease, and especially both, and the risk of amyloidosis and of heart failure (but not death). What are the risks you see? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
The absolute risk is low. A conclusion that we should test or refer everyone with this common diagnosis has potential for iatrogenic, financial, and psychological harm. And the benefit is likely limited. https://pubmed.ncbi.nlm.nih.gov/34097669/ #JHSJC
Brent Graham @BgTalkinman:
In my opinion, this is an association that is real. In fact there is a second paper in this month’s issue on the same topic https://jhandsurg.org/article/S0363-5023(22)00128-9/fulltext #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
I think the VA database is a useful way to study this. And they have shown that clinically relevant amyloidosis is rare. https://pubmed.ncbi.nlm.nih.gov/34097669/ #jhsjc
RyanC @RPCalfeeSTL:
I’m curious if anyone is frequently screening for amyloid or doing samples in selected patients? If so, who gets tested? #jhsjc
Warren @whammert to @BgTalkinman:
I see the point of there being an association, but at what incidence is needed to justify the cost of testing everyone #jhsjc
David Ring @DrDavidRing:
The association is real. How to use it to help people get an stay healthy is several experimental steps in the future. I would urge caution. #jhsjc
RyanC @RPCalfeeSTL:
Association seems real but incidence is still very low so trying to decide what to do with that information #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Agreed – it is rare but it seems real so what are the ramifications for hand surgeons as far as taking some responsibility for incorporating biopsies as a routine? #jhsjc
Dafang Zhang @DafangZhang to @DrDavidRing:
Dr. David Ring makes a great point about the need for risk stratification to identify which patients with “idiopathic” CTS benefit the most from biopsy for amyloid #nextlevel #jhsjc
Warren @whammert to @RPCalfeeSTL:
If you had to pay for the test out of pocket, what increased chance would justify the cost. #jhsjc
RyanC @RPCalfeeSTL:
Great question Warren. I don’t know the answer. What do you or others’ think? #jhsjc
Brent Graham @BgTalkinman to @whammert:
It seems like a public health question to me because the testing is not expensive and the potential to make a difference to a few patients may make it a reasonable. Shouldnt we think of this like we do about tetanus boosters or vaccination for childhood disease? #jhsjc
Dafang Zhang @DafangZhang to @RPCalfeeSTL:
I do screen for amyloid in CTR in men > 50, women > 60 with bilateral symptoms. Exciting to get a positive biopsy, refer to cardiology, and even had patients get started on amyloid medication–great feeling! 😀 #jhsjc
Warren @whammert to @RPCalfeeSTL:
I think I would take my chances. Although there is an association and may be statistically significant, I am not sure how clinically relevant it is. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I understand that is a personal choice but what should we do for the patients? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
The priority for hand surgeons is to consider routine biopsy experimental and generate experimental evidence to establish the relative potential for benefit vs. harm in hand surgeons considering rare diagnoses #jhsjc
David Ring @DrDavidRing to @DafangZhang:
Evidence should lead to more experimentation. Not blind faith. #jhsjc
Warren @whammert to @DafangZhang:
How many positive biopsies have you had? #jhsjc
Dafang Zhang @DafangZhang to @whammert:
I’d estimate 5 in the last year, referred to our cardiologists who specialize in amyloid. our cardiologists are amazing, do the subtyping, technetium scans to assess for cardiac amyloid involvement. I think 1-2 have gotten started on therapy, the rest yearly monitoring. #jhsjc
RyanC @RPCalfeeSTL to @DafangZhang:
Dafang – I’m impressed you had 5 identified. Were those patients requested to have biopsies or did you do it on your own? #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
It is especially surprising if 2 of those 5 ended up being treated! #jhsjc
Dafang Zhang @DafangZhang to @RPCalfeeSTL:
On my own 😀 Our group has gotten keen on biopsying in men > 50, women > 60 w/ b/l symptoms based on Sperry et al study. We’re also lucky to have wonderful amyloid pathologists and cardiologists, and the team effort is really helpful. #jhsjc
Dafang Zhang @DafangZhang to @whammert and @RPCalfeeSTL:
Depends on the rate of positive biopsy, no? Risk stratification can help increase the likelihood of a hit and decrease costs through selective biopsy. #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
i agree. the other study this month (DiBenedetto et al) found no cases in men under 50 or women under 60 so that would be a good starting point for selecting patients in whom to do biopsies. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I agree with that. I would say that hand surgeons haven’t done a great job involving themselves in osteoporosis care despite being in a great position to do so. Will this be the same? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Osteoporosis is a great example. Osteoporosis is part of normal aging. And it’s not clear that any treatments are better than accommodation. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Is it really true that treatment doesn’t help in terms of reducing fracture risk? That isn’t my impression. #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
I agree with DrDavidRing that costing this is important but given the very small relative cost of this kind of screening I would bet that it would prove cost effective – maybe very much so. #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
yeah totally agree with everyone’s great comments. little cost analysis on this topic that i know of… i think cost of H&E and Congo red together is on order of $150, not a ton, but CTR is very common, so can add up to a lot. #jhsjc
Brent Graham @BgTalkinman:
I will guess that we will be seeing much more study about this in the near future #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other study on the use of the #CTS6 by non-experts #jhsjc https://t.co/35GZwpnyHl
I will just say at the outset that this was exactly the objective when the #CTS6 was developed – to model what expert diagnosticians do so that non-experts can do something similar. #jhsjc
One aspect of the study I liked was that both reliability and validity were evaluated. Was the sample appropriate to address those questions? #jhsjc
RyanC @RPCalfeeSTL:
I thought it performed well in this study which is great to see #jhsjc
Warren @whammert to @BgTalkinman:
So has this been implemented as a screening tool in Canada? #jhsjc
Brent Graham @BgTalkinman to @whammert:
I doubt it. These investigators have a lot of experience with distance medicine in their rural location so it is very appropriate in that setting. #jhsjc
Brent Graham @BgTalkinman:
They found that individual items on the CTS-6 were less reliable than the scale as a whole. Does that have any importance in interpreting the performance of the instrument? #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
That is why limiting it to the groups you mentioned is important #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
I like the CTS 6 for bringing people away from the persistent myth of CTS = pain with typing. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
No argument from me there! #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
The CTS 6 uses some obvious elements like palmar abduction weakness/atropy, diminished sensibility. Factors associated with severe median neuropathy. The diagnostic dilemma is usually in the absense of these. #jhsjc
Warren @whammert to @BgTalkinman:
It doesn’t matter how you get the score (12 pts) in terms of probability. I think Tinel’s is variable between providers, but also patients with CTS feel their entire hand is numb #jhsjc
Brent Graham @BgTalkinman to @whammert:
Tinel was one of the least reliable items when looked at on its own but, as expected, the scale as a whole was very reliable – that’s how it should be used. #jhsjc
Warren @whammert to @BgTalkinman:
That was my point – it doesn’t matter how you get to 12 if you get there. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Yes, and I think that reflects what seasoned clinicians know about evaluating these patients – there may be a variety of presentations. The patients aren’t all the same and the scale accommodates that notion. #jhsjc
Brent Graham to @BgTalkinman:
I will answer my own question: I didn’t understand why they looked at the individual items separately because the scale is meant to be used as a unit. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
I think it’s the balance of potential harms vs. potential benefits. I don’t think that’s worked out yet. And that’s true of a lot of medicine. #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
That is a comment about amyloid right? I agree. It’s like PSA testing in men of a certain age. #jhsjc
RyanC to @RPCalfeeSTL:
In less experienced providers it would make sense that physical exam components would be less reliable than elements related to patient history #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Right! And that is why the scale works as a whole and why nobody would ever depend on just one finding to make the diagnosis of #CTS. the weighting of the individual items also helps with that. #jhsjc
Brent Graham @BgTalkinman:
In a future world of more telemedicine and distance medicine, will this paper provide a good basis for diagnosing #CTS by allied health workers and other physician extenders? #jhsjc
Are the values for sensitivity and specificity adequate for use as a screening scale as the authors suggest? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Now we’re talking! https://t.co/ZZTgR0Dhpd #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
I think the analogy is an apt one but I suspect that the rigors of identifying and treating clinically relevant heart failure will be less complicated than prostate cancer. #jhsjc
RyanC @RPCalfeeSTL:
I think a good screening scale. I would like to see patient in person if offering surgery as I feel more confident for that choice then #jhsjc
Warren @whammert to @BgTalkinman:
While you can use as screening with telemedicine, that misses the exam part, which is still a component. So I think good enough for screening, but not definitive dx #jhsjc
Brent Graham to @BgTalkinman to @whammert:
Actually what I am picturing is not so much telemedicine as screening being done by non-surgeons – maybe even non-physicians and referring only patients with a certain threshold score. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I like that! #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Their earlier study last year (https://jhandsurg.org/article/S0363-5023(21)00599-2/fulltext) showed that the #CTS6 performed very well in a telemedicine setting for patients who later came for surgery. #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman and @whammert:
I like the idea, and my only reservation is to your point about sensitivity. the 10-20% with CTS that wouldn’t make the cutoff to referral to a hand surgeon? perhaps we need a lower threshold for referral than the threshold for definitive diagnosis? #jhsjc
Brent Graham @BgTalkinman to @DafangZhang and @whammert:
One of the points of having the scale output be a probability was to allow that kind of flexibility – a decision could be made as to the threshold for referral to maximize either sensitivity or specificity.
Brent Graham @BgTalkinman:
Great discussion for both topics! These were two interesting papers. We are now begin a summer hiatus. We return September 13. A happy and relaxing summertime to all! #jhsjc
